What is the treatment for temporal arteritis?

Treatment for Temporal Arteritis

Immediate high-dose glucocorticoid therapy (prednisone 40-60 mg/day) is the first-line treatment for temporal arteritis and should be initiated immediately upon suspicion of the diagnosis to prevent permanent vision loss. 1

Initial Management

• Emergency treatment:

  • Start prednisone 40-60 mg/day orally immediately upon suspicion of temporal arteritis 1
  • For patients with visual symptoms: Consider IV methylprednisolone 500-1000 mg/day to prevent permanent vision loss 1
  • Do not delay treatment while awaiting biopsy results 1, 2

• Diagnostic confirmation:

  • Temporal artery biopsy should be performed within 2 weeks of starting glucocorticoids 1
  • Long-segment specimen (>1 cm) is preferred to increase diagnostic yield 1
  • In centers with appropriate expertise, temporal artery ultrasound can expedite diagnosis, especially in emergency settings 1, 3

Treatment Algorithm

1. Immediate therapy:

   • Start high-dose glucocorticoids at first suspicion of temporal arteritis
   • Urgent referral to specialist (rheumatology, ophthalmology) 1

2. Adjunctive therapy:

   • Consider tocilizumab to reduce glucocorticoid requirements and prevent relapses 1
   • Add low-dose aspirin (75-150 mg/day) for cardiovascular and cerebrovascular protection if no contraindications 1
   • Implement bone protection therapy to prevent glucocorticoid-induced osteoporosis 1

3. Monitoring:

   • Regular assessment of clinical symptoms
   • Monitor inflammatory markers (ESR, CRP)
   • Watch for glucocorticoid side effects (blood pressure, glucose, cataracts) 1

Clinical Pearls and Pitfalls

• Critical pitfall: Delaying treatment while awaiting biopsy results can lead to permanent vision loss 1, 2, 4

• Important consideration: Relapses are common (34-62% of patients), and only 15-20% achieve sustained remission with glucocorticoids alone 1

• Diagnostic challenge: Symptoms can mimic other conditions including angle-closure glaucoma, hypertension, migraine, and trigeminal neuralgia 5

• Warning signs requiring immediate action:

  • New-onset persistent localized headache (especially temporal)
  • Scalp tenderness
  • Jaw claudication
  • Visual disturbances (amaurosis fugax, diplopia) 1, 2

• Monitoring pitfall: Failing to monitor ESR while tapering steroids can lead to disease reactivation 6

Special Considerations

• Temporal arteritis is considered an ophthalmological emergency due to the risk of rapid, irreversible bilateral vision loss 4

• Even with negative temporal artery biopsy, high-dose prednisone therapy may still be effective in relieving symptoms and lowering sedimentation rate in clinically suspected cases 5

• Patients should be evaluated for large vessel involvement with appropriate imaging 1

• Treatment duration is typically prolonged, with careful monitoring during steroid tapering to prevent relapse 1, 6